Intranasal Corticosteroids in Allergic Rhinitis

Rhinitis is an inflammation of the lining of the nose, causing congestion, rhinorrhoea, sneezing and itching. It is classified as allergic (hay fever) or non-allergic (including drug-induced, irritant, occupational) rhinitis.

Allergic rhinitis is a major respiratory disease due to its increasing prevalence and major impacts on quality of life. It is a major risk factor for asthma. Uncontrolled moderate to severe allergic rhinitis can affect asthma control. Asthma occurs in 30% of patients with allergic rhinitis, and allergic rhinitis occurs in more than 80% of patients with asthma.

Effective treatment of allergic rhinitis can improve asthma symptoms. Sleep disorders and sleep apnoea may also develop from chronic nasal congestion due to allergic rhinitis. Sleep apnoea may result in increased cardiovascular risk, diabetes, depression, and accidents.

Allergic rhinitis is associated with an immunoglobulin E (IgE)-mediated immune response to environmental allergens. These allergens can be seasonal (e.g. pollens) or perennial (e.g. dust mites, pet dander). Chemical irritants, such as cigarette smoke, can further exacerbate symptoms. Allergens should be identified and avoided where possible. Environmental controls, such as general measures to reduce house dust mites, may help improve symptoms.

Intranasal corticosteroids are administered directly to the nasal mucosa in the form of a nasal spray to manage allergic rhinitis, rhinosinusitis (infectious rhinitis) and nasal polyps. INCS reduce the influx of inflammatory cells into the nasal mucosa in response to allergic stimuli. This reduces the release of inflammatory mediators and the development of nasal hyperresponsiveness.

Intranasal corticosteroids are the treatment of choice in patients with moderate to severe allergic rhinitis symptoms and in patients with mild, persistent symptoms. Optimal improvement in symptoms is reached after several days of regular use, although some symptoms may start to improve within a few days. They are still effective if used on an as-needed basis for episodic symptoms.

Sodium chloride 0.9% nasal irrigation may help clear nasal passages by washing out allergens and sticky mucus and reduce congestion and irritation.

Common adverse effects of INCS are:

• Nasal stinging
• Itching
• Nosebleed
• Sneezing
• Sore throat
• Dry mouth and cough

Intranasal corticosteroids rarely cause systemic adverse effects when used at recommended doses. They should be used with caution in patients with glaucoma or cataracts. They are generally considered safe to use in pregnancy. Budesonide, mometasone and fluticasone are preferred in the first trimester as there is greater experience with these agents.

The recommended minimum age for the available INCS are:

• Beclomethasone 50mcg/spray – from age 12 and older
• Budesonide 32mcg/spray or 64mcg/spray – from age 6 and older
• Ciclesonide 50mcg/spray – from age 6 and older
• Fluticasone furoate 27.5mcg/spray – from age 2 and older
• Fluticasone propionate 50mcg/spray – from age 12 and older
• Mometasone 50mcg/spray – from age 3 and over.

General patient counselling points:

• Shake the bottle well before each use.
• Prime the spray before initial use or if it has not been used recently.
• Gently blow nose to clear the nasal passages (or use a saline rinse to clear nasal obstruction and then waiting for 10 minutes before using the nasal spray).
• Tilt head slightly forward.
• Gently insert the nozzle into the left nostril, aiming towards the left ear, away from the septum. Use your right hand for the left nostril and left hand for the right nostril. This reduces the amount of drug deposited onto the septum.
• Press to spray (do not sniff hard, as this can force the dose into the throat).
• Repeat for the other nostril.
• Wipe the tip of the spray device with a dry tissue and put the cap back on.
• Optimal effects may be seen after 7 days of continual use.
• For intermittent symptoms, consider using 2-4 weeks before exposure to know allergens (e.g. pollen) to prevent symptoms.
• If two different nasal sprays are used, there should be an interval of at least 10 minutes between sprays.

Combination products containing an INCS and intranasal antihistamine (INAH) are also available. These formulations are used in patients with allergic rhinitis with moderate to severe symptoms, those with mild, persistent symptoms, and those with mild symptoms not responding to antihistamines. Combination treatments offer the advantages of both medications and are more efficacious and faster acting than monotherapy.

The minimum recommended age for use of INCS/INAH formulations is:

• Azelastine 125mcg/fluticasone propionate 50mcg (Pharmacy Only medicine) – age 12 and older. Offers nasal symptom relief from 5 minutes and ocular symptom relief from 10 minutes.
• Olopatadine 600mcg/spray/mometasone furoate 25mcg (Prescription Only medicine) – age 6 and older. Offers nasal symptom relief from 10 minutes.

Counselling points:

The information that should be provided to patients is much the same as per INCS products.

If the patient is already taking an oral antihistamine, it should be stopped before starting the combination nasal spray. Combining an oral and intranasal antihistamine does not provide additional benefit.

Although the efficacy of each INCS is thought to be similar, choice may be affected by many factors including dosing, cost and tolerability.